Nurse Appeals (Work From Home)
WLPTJP00040775
Manager: Patricia Mitchell
4 Positions (8 Submissions allowed)
8/23/21 - 4/22/22
Location: FL - Off Premises 33606 ( These are work from home positions. Candidates can live anywhere with appropriate State RN licenses.)
Bill: $62.72 = Zone 0 (However, Please USE Rate Card to determine Bill Rates)
Schedule: Need Nurse Staff Monday-Saturday - will be flexible with candidates on work days. 4-10 hour days possible.
Temp can work from home anywhere in the United States. Please refer to 2021 rate card attached in JD and determine appropriate rate based on where candidate resides
Bill Rate Zone 0
Bill Rate Zone 1
Bill Rate Zone 2
Bill Rate Zone 3
Bill Rate Zone 4
Bill Rate Zone 5
Bill Rate Zone 6
$62.72
$60.11
$57.50
$54.88
$52.27
$49.66
$47.04
Skills Required:
- 2-3 years of clinical experience
- RN License.
- Attention to detail
- Experience completing medical necessity reviews in a managed care setting (Utilization Management and/or appeals)
- Ability to learn new applications with ease and work from home independently
- Previous Appeals experience preferred. Previous Medicaid or Medicare experience preferred
JOB SUMMARY ---- Responsible for investigating and processing  and medical necessity appeals requests from members and providers. Primary duties may include, but are not limited to: Conducts investigations and reviews of member and provider medical necessity appeals. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for medical director, consultants and other external review. Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems. Generates written correspondence to providers, members, and regulatory entities. Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues. Requires 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. AS/BS in Nursing preferred.